Professional Documents
Culture Documents
6 JUNE 2008
Medical Bulletin
Introduction
It is well-known that being a doctor is stressful.
Previous studies have shown a higher level of stress
amongst doctors when compared to the general
population. Firth-Cozens1 noted that the proportion of
doctors showing above threshold levels of stress is
around 28%, in cross-sectional and longitudinal
studies, compared to around 18% in the general
working population. There is also evidence to show an
increased rate of psychological morbidity, for example,
depression, anxiety and substance abuse amongst
doctors. Local data are still limited, but there is
preliminary evidence to suggest elevated anxiety,
depression and stress in Hong Kong medical students 2
and interns (unpublished data). Rates of stress are
elevated in all doctors, regardless of the setting in
which they work, but junior doctors and female
doctors are particularly at risk. As doctors, we are
accustomed to identifying stress in our patients. We
inform them about health consequences of excess
stress and advise them on lifestyle changes and
relaxation. The pathology is usually in others, in
patients we look after. Are we then able to identify
stress in ourselves, manage our stress in an adaptive
manner and seek help when such stress becomes too
much to handle?
Sources of Stress
The sources of stress in medical practitioners vary with
the type of medical practice (private vs. public, hospitalbased vs. community-based) and specialty. There are
many potential sources of stress that relate to the job, the
organisation, the doctor himself/herself, work-life
balance and relationships with other people (see Box 1).
Usually, a number of these factors are present in an
individual doctor, and therefore the difficulties faced by
the doctor are compounded and complicated.
In addition, there is an apparent mismatch between what
doctors are trained for and what they are required to do.
For example, in the medical curriculum, there is much
focus on patho-physiology, diagnosis and treatment.
There is now increasing emphasis on communication
skills, law and ethics in medical education. However,
other key aspects of a doctor's job like administrative and
financial management are poorly addressed, and these
often cause stress amongst doctors.
Box 1 Sources of Stress for medical practitioners
The job
Workload
Time pressure
Administrative duties
Sleep deprivation
No regular meals
Threat of malpractice suits
The organisation
Career structure
Career uncertainties
Inadequacy of resources and staff
Lack of senior support
Culture and climate of the organisation
The doctor
Personality (e.g. perfectionistic, Type A)
High demands on self and others
Dealing with death and dying
Confrontation with emotional and physical suffering
Relationships with other people
Staff conflicts
Bullying
Professional isolation
Patient's expectations and demands
Level of support from friends and family
Work-life balance
Stress over-spill from work to home and vice versa
Lack of exercise and other leisure activities
Lack of free time
Home demands
Disruptions to social life
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wishful thinking and emotional distancing, but these do
not work long term. Doctors are also 'poor' patients due
to maladaptive health behaviours 9,10 like selfmedication, not seeking a formal medical consultation
when ill and continuing to work when unwell. Most
doctors do not have their own general practitioner.
Some doctors regard falling ill as shameful, especially
when the illness is psychological in nature. Some think
that they should always be able to master and control
their emotions and it is a sign of weakness when they
experience emotional distress. There are also concerns
about being stigmatised by fellow doctors or being
discriminated against in their career development if
they are in the mental health system.
These attitudes reflect widespread stigma towards
mental illness in the general population and within the
medical profession11.
Medical Students
Barriers to Care
Despite the high prevalence of stress in doctors, and a
myriad of physical and mental health consequences,
doctors are notoriously reluctant to seek help for
themselves8. The subjective experience of being ill is not
taught or much discussed at medical school. Doctors are
often perfectionistic, self-sacrificing people with high
levels of personal drive and altruism. This predisposes
them to put others' needs before their own, thus
increasing stress but their personality also makes it hard
for doctors to self-reflect or to seek help. For most
doctors, stress or illness is what happens to other
people, and doctors are there to help them get better. It
is sometimes very difficult for doctors to acknowledge
their own stress and distress, and even more difficult to
acknowledge that their work performance is affected as
a result. Some doctors deal with stress by engaging in
Medical Bulletin
One example of resources within medical school that
address psychological wellbeing of the student body is
the Programme for Effective Transition and Student
Support (PETSS) at the medical faculty of the University
of Hong Kong13. PETSS aims to promote mental health
literacy, with student support services and activities to
develop leadership within the student body. There are
primary prevention activities that aim to enhance mental
health awareness and resilience in medical students e.g.
an educational website on mental health issues designed
by medical students in a Mental Health Support Group14,
workshops on time management, study skills,
mindfulness-based stress reduction, emotional and social
competence, etc. In addition, there is a buddy scheme in
which Year 1 students are mentored by more senior
medical students to help them adapt to life in university.
Secondary prevention strategies that aim at helping 'at
risk' medical students include the establishment of a
Wellbeing Committee that consists of a group of
volunteer teachers who provide support and counselling
to students in need. The issues that students bring to the
Wellbeing Committee include emotional problems,
relationship issues, study difficulties, doubts about
commitment to the course, etc. In addition, the Mental
Health Support Group14, a pioneering student-initiated
peer support network for fellow medical students runs a
discussion forum and offers email counselling for
individuals. Mental Health Support Group members are
trained in Mental Health First Aid and basic counselling
such that they can respond appropriately if they come
across students in distress. Preliminary evaluation
suggests that MSG services are welcomed by medical
students. These are specific services for medical students.
Students can also access generic support services
provided by the university itself through its health
service or counselling centre.
Practising Doctors
For practising doctors, organisational and occupational
changes such as increasing support for staff, reducing
non-medical workload, and reducing working hours are
all likely to reduce mental stress in doctors. The
establishment of Oasis15 at the Hospital Authority in 2002
was one example of how primary prevention can be
initiated by an employer. Oasis, Centre for Personal
Growth and Crisis Intervention, aims to promote a
culture of care within the Hospital Authority. It organises
primary prevention activities to enhance staff members'
ability to develop and mobilise their own inner resources
to overcome life's difficulties. There are educational talks,
workshops (for example on resilience training, life
education) and quiet rooms which provide an
environment in which to meditate and have time to
oneself. There is also training of critical incident
management teams in each hospital in order to facilitate
and coordinate timely staff support in case of a crisis, for
example suicide of a colleague or a serious medical error.
In addition, Oasis also provides treatment by clinical
psychologists for health care workers (including doctors)
who are at risk or already impaired, in a safe and
confidential setting away from their usual workplace.
It is heartening to see that seeds appear to be sowed for a
culture change within the medical profession such that
high stress is acknowledged and taking steps to enhance
one's own mental health is no longer embarrassing or
VOL.11 NO.5
MAY
20062008
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NO.6
JUNE
Medical Bulletin
References
1. Firth-Cozens J. Doctors, their wellbeing, and their stress. BMJ 2003
Mar 29; 326:670-671.
2. Wong JGWS, Patil NG, Beh SL, Cheung EPT, Wong V, Chan LC, et
al. Cultivating psychological well-being in Hong Kong's future
doctors. Medical Teacher 2005; 27(8): 715-719.
3. Lazarus R, Folkman S. Stress, appraisal and coping. New York:
Springer; 1984.
4. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev
Psychol 2001;52:397-422.
5. McManus IC, Winder BC, Gordon D. The causal links between
stress and burnout in a longitudinal study of UK doctors. The
Lancet 2002; 359: 2089-2090.
6. Crane M. Why burned-out doctors get sued more often. Medical
Economics 1998 May 26; 75(10): 210-215.
7. Firth-Cozens J. Interventions to improve physicians' well-being
and patient care. Social Science and Medicine 2001; 52: 215-222.
8. Adshead G. Healing ourselves: ethical issues in the care of sick
doctors. Advances in Psychiatric Treatment 2005; 11: 330-337.
9. Chamber R, Belcher J. Self-reported health care over the past 10
years: a survey of general practitioners. Br J Gen Pract. 1992;
42:153-156.
10. Forsythe M, Calnan M, Wall B. Doctors as patients: postal survey
examining consultants and general practitioners adherence to
guidelines. BMJ 1999; 319: 605-608.
11. The Royal College of Psychiatrists. Mental illness: stigma and
discrimination within the medical profession. London: The Royal
College of Psychiatrists; 2001.
12. The Royal College of Psychiatrists. The mental health of students in
higher education. London: The Royal College of Psychiatrists; 2003.
13. Programme for Effective Transition and Student Support [Online].
[Cited
2008
Mar
31].
Available
from
URL:
http://www.hku.hk/facmed/imhse/core5.html.
14. Lau KS, Siong KH, Tang HY, Cheng, PW, Cheung KS, Chan SW, et
al. An innovative web-based peer support system for medical
students in Hong Kong. Medical Teacher 2007; 29: 984-986.
15. Oasis [Online]. [Cited 2008 Mar 31]. Available from URL:
http://www.ha.org.hk/oasis/.
16. Schattner P, Davidson S, Serry N. Doctors' health and wellbeing:
taking up the challenge in Australia. MJA 2004; 181(7): 348-349.
17. British Medical Association. Doctors' health and wellbeing.
[Online]. [Cited 2008 Mar 31]. Available from URL:
http://www.bma.org.uk/ap.nsf/Content/Hubhealthandwellbeing